More of our loved ones who are getting older or have special medical needs requiring basic health care assistance are getting the help they require at home instead of in a facility or institutional setting.

The VA has been expanding long-term care (LTC) services to veterans in the home or in a community setting, as have other public health care systems, as more veterans and their families desire to age in place. This comes at a time when the country has contended with widespread COVID-19 outbreaks in LTC facilities such as nursing homes while also dealing with the rapidly growing elderly population — one study estimated the growth in LTC employment between 2010 and 2030 at 79%.

Veterans rely on VA LTC for everything from occasional help around the house to around-the-clock care. Eligibility is primarily based on the extent of a service-connected disability. 

[FROM VA.GOV: Long-Term Care Services]

To gain a better perspective of veterans’ access to home and community-based services, the House Veterans’ Affairs Subcommittee on Health conducted a hearing on July 27 to address what the chair, Rep. Julia Brownley (D-Calif.) refers to as a "‘silver tsunami’ – a massive wave of Americans and veterans requiring LTC, the scale of which is too big to ignore.”

While VA delivers 14 different types of LTC programs in both institutional settings (like community living centers or nursing homes), and non-institutional settings (like a veteran’s home or through community adult day care services), purchasing or providing the care is placing increased demand on the department’s health care system.

“VA’s various LTC programs provide a continuum of services to help meet veterans’ needs over time,” Dr. Scotte Hartronft, VA’s executive director for geriatrics and extended care (GEC) told lawmakers. “VA recognizes more needs to be done to accelerate home care. It is also critical to continue providing the funds needed for moving forward on these programs.”

[MORE FROM MOAA: Long Term Care Insurance and More Resources]

From FY 2014 to FY 2018, demand for LTC increased 14% and VA’s expected spending went up 33%. The VA projects demand will continue to grow, with spending set to double by 2037.    

Know Your Care Options

Today, VA’s LTC programs serve 439,970 veterans — 73% are 65 years and older and 20% are 85 years or older. About 85% of veterans in the program are receiving care at home.

Two newer extended care programs are the Veteran-Directed Care Program (VDCP) and Medical Foster Homes.

VDCP is one of the more popular programs and garnered a lot of attention during the hearing as a potential model for delivery of other VA health care services. The program is for veterans of all ages enrolled in VA health care who meet the clinical need criteria for services. Veterans in VDCP are given a flexible budget from the VA to purchase services that they or a family caregiver can manage as they see fit – a unique approach among VA programs.

Medical Foster Homes, on the other hand, are an alternative to a nursing home. Care is delivered to a small number of veterans and non-veterans in a private-home setting where trained caregivers provide care and supervision 24 hours a day, seven days a week. Most expenses for care fall on the veteran, their family, or a legal representative.

[AUG. 25 WEBINAR: Know Your VA Benefits]

Barriers for Veterans Accessing LTC

Lawmakers focused extensively on a February 2020 Government Accountability Office (GAO) report identifying three key challenges the VA faces in meeting the growing demand for LTC services. These issues aren’t unique to the VA and are common in other health care systems nationwide:

• Workforce shortages. The VA continues to grapple with hiring and retaining geriatricians and palliative care providers, and with caregiving staff in other areas such as nursing assistant and health technician positions. Shortages contribute to growing wait lists for certain programs.

• Geographic alignment of care. The VA struggles to align its services to where veterans live because of demographic shifts in the veteran population. Providing care to veterans in rural areas is especially challenging because of the lack of adequate workforce and infrastructure to support the delivery of care.

• Difficulty meeting veterans’ needs for specialty care. Finding appropriate LTC for veterans with dementia, behavioral health conditions, ventilator care, or other specialized needs is challenging and costly.

GAO noted the VA had yet to develop measurable goals to address these challenges.

Brownley voiced concern during the hearing that the VA had not yet acted on GAO’s recommendations, holding up a two-page document representing GEC’s Elder Care Strategic Plan from last year.

“A plan without a plan is a plan to fail,” she said; “The committee needs sufficient detail to be able to oversee and ensure goals are being accomplished.”

Like MOAA, the Elizabeth Dole Foundation (EDF) and the Paralyzed Veterans of America (PVA) support expanding LTC programs, including VDCP. Witnesses from these groups called attention to other barriers facing veterans and their caregivers and families at the hearing:

• Difficulty in finding and managing caregivers or home care workers. PVA gave one example of a quadriplegic veteran who had to interview more than 400 potential caregivers over a 10-year period. These workers are paid low wages. Agencies typically charge 20-25% above what a worker is paid, so if the VA authorizes $20, the worker makes only $12 or $13 per hour.

• Caregivers are not integrated into VA’s LTC programs. EDF talked about burnout of caregivers during the pandemic. VA’s respite care is disjointed and needs to be easier to access. Caregivers help veterans stay in their homes, saving the VA from covering more expensive care in an institutional setting.

• VA LTC programs are not aligned to veterans’ needs. Programs should put veterans and their caregivers at the center of health care like VDCP. That means building caregiving support around them, not a one-size-fits-all approach typical of the VA.

Subcommittee members were particularly baffled at why more VA medical centers have not adopted VDCP, especially as PVA testified that each medical center needs only a master level social worker to coordinate the program. VDCP is very popular and allows veterans and their families control over how benefit dollars will be spent.   

Hartronft told members LTC is available in all medical centers except for the two newer programs, VDCP and Medical Foster Care.

“We really are trying to expand VDCP as quickly as possible and communicating awareness of the program,” he said, adding that the VA “can never overcommunicate with veterans on how they can access these programs.”

Currently only 69 of the 171 medical centers administer the program.

[RELATED: What’s Next for VA’s Troubled Electronic Health Records Program?]

What Can Veterans and Their Caregivers Expect?

The challenges and desire to improve VA LTC programs did not fall on deaf ears with subcommittee members.

Brownley warned the subcommittee would be watching and making sure the department accelerates its efforts to expand VDCP and other LTC programs. 

She also suggested reforms for all VA LTC programs were needed to integrate caregiver support, respite care, mental health, and telehealth services more fully within the continuum of care.

“I want to put together a package of LTC programs that works for veterans,” she said. “It’s about veterans having a one-stop-shop place to go to get the care they deserve.”

Many of the issues brought up during the hearing are long-standing priorities for MOAA. In 2021 joint testimony to the House and Senate on veteran priorities, MOAA urged Congress and the VA to expand access to caregiving, palliative care, geriatric care, extended care, and hospice programs and services for veterans and wounded warriors and their caregivers.

Like the subcommittee, MOAA will keep our eyes fixed on VA’s progress. These necessary improvements and expansions will help ensure veterans are able to live out their remaining years in the most meaningful way possible and with the dignity they deserve.